White coat effect in treated and untreated patients with high office blood pressure. Relationship with pulse wave velocity and left ventricular mass index.

OBJECTIVE: To evaluate in hypertensive patients whether the white coat effect is associated with target-organ damage and whether it is modified by anti-hypertensive therapy. METHODS: In a cross-sectional study we evaluated blood pressure (BP) measured in the office and by 24-h ambulatory blood pressure monitoring (ABPM), carotid-femoral pulse wave velocity (PWV) as an index of aortic stiffness, and left ventricular mass index (LVMI) in 88 subjects (aged 49 +/- 2 years) with white-coat hypertension (WCH, office BP > 140/90, daytime BP < 130/84 mmHg), 31 under antihypertensive therapy, 57 untreated, and in 115 patients with office and ambulatory hypertension (HT, aged 51 +/- 2 years, office BP > 140/90, daytime BP > 135/85), 65 under antihypertensive therapy, 50 untreated. In a longitudinal study in 15 patients with HT and in 11 patients with WCH we evaluated the influence of antihypertensive therapy (> 6 months) on office and ambulatory BP and on PWV. RESULTS: The intensity of the white coat effect (office BP-daytime BP) was greater in WCH than in HT. Taking all subjects, the white coat effect did not correlate with PWV (r = 0.08, ns) or with LVMI (r = 0.01, ns), whereas daytime BP correlated significantly with PWV (r = 0.41, p < 0.01) and with LVMI (r = 0.32, p < 0.05). WCH subjects showed lower PWV and LVMI than HT subjects. Treated and untreated WCH, with similar office and daytime BP, showed similar values of PWV and LVMI. Treated and untreated HT showed similar office BP values but treated HT showed lower daytime BP and PWV values. In the longitudinal study, antihypertensive therapy significantly reduced daytime BP and PWV values in the 15 HTs, whereas in the 11 WCH it did not alter daytime BP or PWV values. CONCLUSIONS: 1. In both WCH and HT (treated and untreated) the intensity of the white coat effect does not reflect either the severity of hypertension measured by target organ damage or the efficacy of antihypertensive treatment. 2. In WCH antihypertensive therapy does not improve either ambulatory BP values or damage to target organs.     

Awake systolic blood pressure variability correlates with target-organ damage in hypertensive subjects

Growing evidence associates blood pressure (BP) variability with cardiovascular events in hypertensive patients. Here we tested the existence of a relationship between awake BP variability and target-organ damage in subjects referred for suspected hypertension. Systolic and diastolic BP variability were assessed as the standard deviation of the mean out of 24-hour, awake and asleep BP recordings in 180 untreated subjects, referred for suspected hypertension. Measurements were done at 15-minute intervals during daytime and 30-minute intervals during nighttime. Left ventricular mass index (by echo), intima-media thickness (by carotid ultrasonography), and microalbuminuria were assessed as indices of cardiac, vascular and renal damage, respectively. Intima-media thickness and left ventricular mass index progressively increased across tertiles of awake systolic BP variability (P for trend=0.001 and 0.003, respectively). Conversely, microalbuminuria was similar in the 3 tertiles (P=NS). Multivariable analysis identified age (P=0.0001), awake systolic BP (P=0.001), awake systolic BP variability (P=0.015) and diastolic BP load (P=0.01) as independent predictors of intima-media thickness; age (P=0.0001), male sex (P=0.012), awake systolic (P=0.0001) and diastolic BP (P=0.035), and awake systolic BP variability (P=0.028) as independent predictors of left ventricular mass index; awake systolic BP variability (P=0.01) and diastolic BP load (P=0.01) as independent predictors of microalbuminuria. Therefore, awake systolic BP variability by non-invasive ambulatory BP monitoring correlates with sub-clinical target-organ damage, independent of mean BP levels. Such relationship, found in subjects referred for recently suspected hypertension, likely appears early in the natural history of hypertension.     

Ethnic differences in sleep quality accompany ethnic differences in night-time blood pressure dipping

BACKGROUND: African Americans exhibit a smaller nocturnal decrease in blood pressure (BP) than whites, and there are also reports of poorer sleep quality among African Americans. We examined the contribution of sleep quality to ethnic differences in BP dipping in African American and white male and female college students. We hypothesized that African Americans would exhibit blunted nocturnal BP dipping compared to whites, which would be partly accounted for by poorer sleep quality among African Americans. METHODS: Forty-three African American and 46 white college students aged 18 to 25 years completed an ambulatory BP protocol that included wrist actigraphy, which was used in conjunction with participant self-reports of sleep times for analyses of sleep quality. RESULTS: Although daytime and night-time BP did not differ according to ethnicity, African Americans had a smaller dip in systolic BP (P < .01), and African American women had a smaller dip in diastolic BP than whites (P < .01). Whites were more likely to be classified as a dipper (71%) than African Americans (41%) (P < .01). African Americans, compared to whites, spent less time in bed, were asleep for a shorter period of time, took longer to fall asleep, exhibited poorer sleep efficiency, and were awakened a higher percentage of the time by the inflation of the BP cuff (F > or = 4.85, P < .05). However, sleep quality did not appear to contribute to ethnic differences in diastolic BP dipping. CONCLUSIONS: Sleep quality accompanied ethnic differences in systolic and diastolic BP dipping, but did not account for these differences.     

Value of home blood pressures as predictor of target organ damage in mild arterial hypertension

BACKGROUND: Home blood pressure measurement has gained increasing importance for the management of hypertensive patients. The aim of our study was to compare levels of clinic (CBP), ambulatory (ABP), and home blood pressure (HBP) measurements, and their relationships with various indexes of target organ damage in I-II grade essential hypertension. DESIGN AND METHODS: Thirty-eight essential hypertensives underwent evaluation of clinic, ambulatory and home blood pressures. Each patient recorded HBP for 2 days with a digital BP monitor three times daily, the first time on the same day during which ABP monitoring was simultaneously performed. Moreover, in all subjects electrocardiogram recording, echocardiographic study, microalbuminuria assay and fundus oculi examination were obtained. RESULTS: The average HBPs obtained on the first day, in particular systolic values, were quite similar to mean daytime ambulatory BP recorded on the same day. Clinic BP, both systolic and diastolic, showed no significant correlation with left ventricular mass index (LVMI) and with albumin excretion rate (AER), whereas a correlation barely significant was observed with an index of global target organ damage (GTODi), including cardiac, renal and retinal parameters. On the contrary, home blood pressures, especially those recorded on the second day, correlated significantly, and more tightly than clinic BP, with LVMI, AER and GTODi. CONCLUSIONS: Our study seems to justify the adoption of home BP monitoring in the management of hypertensive patients, as a useful complement to clinical readings, and may provide additional prognostic information.     

Assessment of blood pressure in patients with Type 2 diabetes: comparison between home blood pressure monitoring, clinic blood pressure measurement and 24-h ambulatory blood pressure monitoring.

AIMS: To compare a home blood pressure (BP) monitoring device and clinic BP measurement with 24-h ambulatory BP monitoring in patients with Type 2 diabetes mellitus (DM). METHODS: Fifty-five patients with type 2 DM had BP measured at three consecutive visits to the DM clinic by nurses using a stethoscope and mercury sphygmomanometer (CBP). Twenty-four-hour ambulatory BP was measured using a Spacelabs 90207 automatic cuff-oscillometric device (ABPM). Subjects were then instructed in how to use a Boots HEM 732B semiautomatic cuff-oscillometric home BP monitoring device and measured BP at home on three specified occasions on each of 4 consecutive days at varying times (HBPM). RESULTS: Correlations between HBPM and ABPM were r = 0.88, P < 0.001 for systolic BP and r = 0.76, P < 0.001 for diastolic BP, with correlations between CBP and ABPM being systolic r = 0.59, P < 0.001, diastolic r = 0.47, P < 0.001. HBPM agreed with ABPM more closely compared with CBP (CBP +10.9/+3.8 (95% confidence intervals (CI) 6.9, 14.8/1.6, 6.1) vs. HBPM +8.2/+3.7 (95% CI 6.0, 10.3/2.0, 5.4)). The sensitivity, specificity and positive predictive value of HBPM in detecting hypertension were 100%, 79% and 90%, respectively, compared with CBP (85%, 46% and 58%, respectively). CONCLUSIONS: In patients with Type 2 DM, home BP monitoring is superior to clinic BP measurement, when compared with 24-h ambulatory BP, and allows better detection of hypertension. It would be a rational addition to the annual review process. Diabet. Med. 18, 431-437 (2001)     

Home blood pressure in poorly controlled hypertension: relationship with ambulatory blood pressure and organ damage

OBJECTIVES: (1) To assess whether home blood pressure measurement is a reliable alternative to ambulatory blood pressure monitoring for the evaluation of treated patients with inadequate blood pressure control at the clinic; and (2) to evaluate the relationship between home blood pressure and several target-organ damage markers. BASIC METHODS: A cross-sectional study was performed in 225 treated hypertensive patients with persistently high blood pressure values at the clinic (systolic blood pressure 140 mmHg and/or diastolic blood pressure 90 mmHg). All study participants underwent clinic blood pressure measurement, 24-h ambulatory blood pressure and home blood pressure monitoring. A subgroup of patients underwent the following procedures: carotid echography (n=74), microalbuminuria determination (n=88) and echocardiography (n=43). We defined out-of-clinic normotension as an average ambulatory or home blood pressure less than 135 mmHg (systolic) and 85 mmHg (diastolic). MAIN RESULTS: The sensitivity, specificity and positive and negative predictive values of the home blood pressure method for predicting out-of-clinic normotension (with the ambulatory method used as reference), expressed as percentages, were 50, 87, 64 and 79%, respectively. Systolic home blood pressure correlated significantly with left ventricular mass (r=0.33, P<0.05) and microalbuminuria (r=0.24, P<0.05). Similar correlation coefficients were found for systolic ambulatory blood pressure (r=0.32, P<0.05 and r=0.24, P<0.05, respectively). Clinic blood pressure did not correlate with either left ventricular mass or microalbuminuria (r=0.19, P=0.09 and r=0.19, P=0.24, respectively). Diastolic home blood pressure, but not ambulatory blood pressure, correlated negatively with mean carotid intima-media thickness (r=-0.27, P<0.05). CONCLUSION: Our results suggest that, in patients with poorly controlled hypertension at the clinic, home blood pressure represents a complementary test rather than an alternative to ambulatory blood pressure, and correlates with several target-organ damage markers.     

Weekly Variation of Home and Ambulatory Blood Pressure and Relation Between Arterial Stiffness and Blood Pressure Measurements in Community-Dwelling Hypertensives

Although blood pressure (BP) is a major determinant of pulse wave velocity (PWV), some treatments have independent effects on BP and arterial stiffness. Although both ambulatory BP (ABP) and self-measured BP at home (HBP) have become important measures for the diagnosis and management of hypertension, single day recordings may be insufficient for a proper diagnosis of hypertension or the evaluation of treatment efficacy. To evaluate weekly variations in BP using 7-day HBP and 7-day ABP monitoring and to determine the relation between arterial stiffness and BP measurements in community-dwelling patients with hypertension. We enrolled 68 community-dwelling hypertensive subjects in this study. Significant weekly variations in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were found in the awake ABP data (p < .01, respectively), while no significant weekly variations in the asleep ABP or the morning and evening HBP data were observed. In untreated subjects, significant correlations were obtained between the brachial-ankle PWV and the average awake SBP, the average asleep SBP and the average SBP measured by HBP in the evening. In treated subjects, only the average SBP measured by HBP in the morning was significantly correlated with the baPWV. Differences in the weekly variations in BP were observed between HBP and ABP monitoring. In addition, the morning systolic HBP was not correlated with arterial stiffness in untreated subjectswith hypertension but was correlated in treated subjects. Relations between the morning HBP and arterial stiffness might be attributed to morning surges in BP and/or trough levels of antihypertensive drugs.     

Weekly variation of home and ambulatory blood pressure and relation between arterial stiffness and blood pressure measurements in community-dwelling hypertensives

Although blood pressure (BP) is a major determinant of pulse wave velocity (PWV), some treatments have independent effects on BP and arterial stiffness. Although both ambulatory BP (ABP) and self-measured BP at home (HBP) have become important measures for the diagnosis and management of hypertension, single day recordings may be insufficient for a proper diagnosis of hypertension or the evaluation of treatment efficacy. To evaluate weekly variations in BP using 7-day HBP and 7-day ABP monitoring and to determine the relation between arterial stiffness and BP measurements in community-dwelling patients with hypertension. We enrolled 68 community-dwelling hypertensive subjects in this study. Significant weekly variations in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were found in the awake ABP data (p < .01, respectively), while no significant weekly variations in the asleep ABP or the morning and evening HBP data were observed. In untreated subjects, significant correlations were obtained between the brachial-ankle PWV and the average awake SBP, the average asleep SBP and the average SBP measured by HBP in the evening. In treated subjects, only the average SBP measured by HBP in the morning was significantly correlated with the baPWV. Differences in the weekly variations in BP were observed between HBP and ABP monitoring. In addition, the morning systolic HBP was not correlated with arterial stiffness in untreated subjects with hypertension but was correlated in treated subjects. Relations between the morning HBP and arterial stiffness might be attributed to morning surges in BP and/or trough levels of antihypertensive drugs.     

Circadian blood pressure variation in patients with type 2 diabetes--relationship to macro- and microvascular subclinical organ damage

Aims

To explore the association between nocturnal blood pressure (BP) dipper status and macro- and microvascular organ damage in type 2 diabetes.

Methods

Cross-sectional data from 663 patients with type 2 diabetes, aged 55–66 years, were analysed. Nurses measured office BP and ambulatory BP during 24 h. Individuals with ≥10% difference in nocturnal systolic blood pressure (SBP) relative to daytime values were defined as dippers. Non-dippers were defined as <10% nocturnal decrease in SBP. Estimated glomerular filtration rate (GFR) was calculated and microalbuminuria was measured by albumin:creatinine ratio (ACR). Aortic pulse wave velocity (PWV) was measured with applanation tonometry over the carotid and femoral arteries.

Results

We identified 433 dippers and 230 subjects with a nocturnal non-dipping pattern. Nocturnal SBP dipping was independently of office SBP associated with decreased PWV (p = 0.008), lower ACR (p = 0.001) and NT-proBNP (p = 0.001) and increased GFR (p < 0.001).

Conclusions

We conclude that diurnal BP variation provides further information about early macro- and microvascular subclinical organ damage that goes beyond standardized office BP measurements in patients with type 2 diabetes.     

Ambulatory blood pressure monitoring versus self-measurement of blood pressure at home: correlation with target organ damage

OBJECTIVE: Ambulatory blood pressure (BP) monitoring and home blood pressure measurements predicted the presence of target organ damage and the risk of cardiovascular events better than did office blood pressure. METHODS: To compare these two methods in their correlation with organ damage, we consecutively included 325 treated (70%) or untreated hypertensives (125 women, mean age = 64.5 +/- 11.3) with office (three measurements at two consultations), home (three measurements morning and evening over 3 days) and 24-h ambulatory monitoring. Target organs were evaluated by ECG, echocardiography, carotid echography and detection of microalbuminuria. Data from 302 patients were analyzed. RESULTS: Mean BP levels were 142/82 mmHg for office, 135.5/77 mmHg for home and 128/76 mmHg for 24-h monitoring (day = 130/78 mmHg; night = 118.5/67 mmHg). With a 135 mmHg cut-off, home and daytime blood pressure diverged in 20% of patients. Ambulatory and Home blood pressure were correlated with organ damage more closely than was office BP with a trend to better correlations with home BP. Using regression analysis, a 140 mmHg home systolic blood pressure corresponded to a 135 mmHg daytime systolic blood pressure; a 133 mmHg daytime ambulatory blood pressure and a 140 mmHg home blood pressure corresponded to the same organ damage cut-offs (Left ventricular mass index = 50 g/m, Cornell.QRS = 2440 mm/ms, carotid intima media thickness = 0.9 mm). Home-ambulatory differences were significantly associated with age and antihypertensive treatment. CONCLUSION: We showed that home blood pressure was at least as well correlated with target organ damage, as was the ambulatory blood pressure. Home-ambulatory correlation and their correlation with organ damage argue in favor of different cut-offs, that are approximately 5 mmHg higher for systolic home blood pressure.     

Nurse-recorded and ambulatory blood pressure predicts treatment-induced reduction of left ventricular hypertrophy equally well in hypertension: results from the Swedish irbesartan left ventricular hypertrophy investigation versus atenolol (SILVHIA) study

OBJECTIVE : To compare the relationships of treatment-induced reductions of left ventricular hypertrophy to the changes in clinic and ambulatory blood pressure (BP). DESIGN : Double-blind and randomized treatment with irbesartan or atenolol for 48 weeks. PATIENTS : Patients with hypertension and left ventricular hypertrophy (n = 66) with a seated diastolic BP 90-115 mmHg (average of three measurements one minute apart by nurses). MAIN OUTCOME MEASURES : Registrations of echocardiographic left ventricular (LV) mass. Clinic and ambulatory BP. RESULTS : In the total material, nurse-measured BP was reduced by 23 +/- 15/16 +/- 7.7 mmHg and 24-h ambulatory BP fell 20 +/- 15/14 +/- 8.5 mmHg by treatment. The correlation between the change in nurse-measured BP and LV mass index (LVMI) induced by treatment was r = 0.35, P = 0.004 for systolic BP and r = 0.26, P = 0.03 for diastolic BP. Corresponding values for 24-h ambulatory BP were r = 0.29, P = 0.02 and r = 0.35, P = 0.004, respectively, with similar correlations for day- and night-time ambulatory BP. The nurse-recorded BP was slightly higher than ambulatory BP (systolic clinic - systolic 24-h ambulatory BP = 5 mmHg). Using 130/80 mmHg as a cut-off value for normal 24-h ambulatory BP, eight subjects had normal diastolic or systolic ambulatory BP, or both. Interestingly, these patients also experienced LVMI regression following treatment (low/normal ABP, -13 +/- 21 g/m2; remaining patients, -18 +/- 22 g/m2, P > 0.5). CONCLUSIONS : In patients with hypertension and left ventricular hypertrophy, ambulatory BP is not superior to carefully standardized nurse-recorded seated BP in terms of associations with treatment-induced changes in LV mass.     

The influence of age on blood pressure evaluation of hypertensive subjects

The aim of this study was to determine whether age influences the concordance between different methods of blood pressure (BP) measurement and ambulatory BP monitoring (ABPM) in hypertensive subjects. We studied two groups: I, individuals younger than 50 years (n = 57), and II, individuals aged 60 years or older (n = 55). They were submitted to the performance of one ABPM, office BP measurements, home BP monitoring (HBPM), and BP measurements at a public health center (PHCBP). Student's t-test, Fisher's test and Lin coefficient were calculated. For Group II, systolic and diastolic pressures measured by HBPM were higher than by day ABPM (p < 0.01). The concordance between day ABPM and the other methods was lower for Group II than for Group I. There was a good concordance between systolic day ABPM and office BP, and between systolic ABPM and PHCBP only for Group I (Lin coefficient = 0.71 and 0.73). Group II reported better sleep quality after ABPM (p < 0.05). Considering 24-h ABPM, 52.6% of Group I and 29% of Group II were controlled (p < 0.01). Concluding, there was worse concordance between different methods of BP measurements and day ABPM in the older group, which had lower hypertension control rate and better tolerance of ABPM.     

Circulating platelet‐derived extracellular vesicles correlate with night‐time blood pressure and vascular organ damage and may represent an integrative biomarker of vascular health

Elevated office blood pressure (BP) has previously been associated with increased levels of circulating extracellular vesicles (EVs). The present study aimed to assess the relationship between levels of platelet derived EVs, ambulatory BP parameters, and pulse wave velocity as a marker of macrovascular organ damage. A total of 96 participants were included in the study. Platelet‐derived extracellular vesicles (pEVs) were evaluated by flow cytometry (CD41+/Annexin v+). BP evaluation included unobserved automated office BP and ambulatory BP monitoring. Carotid‐femoral pulse wave velocity (PWV) was measured as a marker of macrovascular damage. pEVs correlated with nocturnal systolic BP (r = 0.31; p = .003) and nocturnal dipping (r = ‐0.29; p = .01) in univariable analysis. Multivariable regression models confirmed robustness of the association of EVs and nocturnal blood pressure (p = .02). In contrast, systolic office, 24h‐ and daytime‐BP did not show significant associations with pEVs. No correlations were found with diastolic BP. Circulating pEVs correlated with pulse wave velocity (r = 0.25; p = .02). When comparing different hypertensive phenotypes, higher levels of EVs and PWV were evident in patients with sustained hypertension compared to patients with white coat HTN and healthy persons. Circulating platelet derived EVs were associated with nocturnal BP, dipping, and PWV. Given that average nocturnal BP is the strongest predictor of CV events, platelet derived EVs may serve as an integrative marker of vascular health, a proposition that requires testing in prospective clinical trials.     

Automated office blood pressure is in agreement with awake and mean 24‐hour ambulatory blood pressure at the lower blood pressure range

Automated office blood pressure measurement eliminates the white coat effect and is associated with awake ambulatory blood pressure. This study examined whether automated office blood pressure values at lower limits were comparable to those of awake and mean 24‐hour ambulatory blood pressure. A total of 552 patients were included in the study, involving 293 (53.1%) men and 259 (46.9%) women, with a mean age 55.0 ± 12.5, of whom 36% were treated for hypertension. Both systolic and diastolic automated office blood pressures exhibited lower values compared to awake ambulatory blood pressure among 254 individuals with systolic automated office blood pressure <130 mm Hg (119 ± 8 mm Hg vs 125 ± 11 mm Hg, P < .0001 and 75 ± 9 mm Hg vs 79 ± 9 mm Hg, P < .0001 for systolic and diastolic BPs, respectively). Furthermore, the comparison of systolic automated office blood pressure to the mean 24‐hour ambulatory blood pressure levels also showed lower values (119 ± 8 vs 121 ± 10, P = .007), whereas the diastolic automated office blood pressure measurements were similar to 24‐hour ambulatory blood pressure values. Our findings show that when automated office blood pressure readings express values <130/80 mm Hg in repeated office visits, further investigation should be performed only when masked hypertension is suspected; otherwise, higher automated office blood pressure values could be used for the diagnosis of uncontrolled hypertension, especially in individuals with organ damage.     

Forty-eight-hour ambulatory blood pressure and carotid-femoral pulse wave velocity in hemodialysis patients

Carotid-femoral pulse wave velocity (cfPWV) is an important predictor of cardiovascular events in the general population and also in hemodialysis (HD) patients. In the general population, cfPWV is strongly associated with age and blood pressure (BP). The best timing and method of BP measurement in HD patients is uncertain. Ambulatory blood pressure measurements (ABPM) have been used to better define the relationship between BP, target organ damage, and outcomes in HD patients. The aim of this study was to determine the possible association between cfPWV, cardiovascular risk factors, single BP measurements, and 48-hour ABPM in chronic HD patients. Thirty-three HD patients (22 men, 11 women) were included. After the end of the mid-week HD session, BP was measured, arterial stiffness was estimated by cfPWV, and 48-hour ABPM was performed. The mean systolic and diastolic BP readings before cfPWV measurement were 136/79 mmn Hg, and the mean 48-hour systolic and diastolic BP readings were 131/76 mm Hg. The mean and range of the cfPWV measurements were 8.31 ± 2.35 m/s and 5.18-16.53 m/s, respectively. Using regression analysis, no association between cfPWV and BP before PWV measurements was found. A statistically significant correlation between cfPWV and 48-hour systolic and diastolic ABPM was found. Using multiple regression analysis (including age, sex, smoking, diabetes, body mass index, total cholesterol, low- and high-density lipoprotein cholesterol, triglycerides, C-reactive protein, albumin, phosphorus, calcium, and iPTH) 48-hour systolic (P < 0.001) and diastolic ABPM (P < 0.005) still remain significantly associated with cfPWV. Only 48-hour ABPM was associated with cfPWV in HD patients in our study. We found no relationship between cfPWV and other cardiovascular risk factors.     

Home-measured blood pressure is more strongly associated with electrocardiographic left ventricular hypertrophy than is clinic blood pressure: the Finn-HOME study

Electrocardiographic evidence of left ventricular hypertrophy (ECG-LVH) has a grave prognostic significance in hypertensive patients. The purpose of our study was to assess whether ECG-LVH is more strongly associated with home-measured blood pressure (BP) than with clinic BP, and whether the correlation between home BP and ECG-LVH increases with the number of home measurements performed. We studied a representative sample of the general adult population (1989 subjects 45-74 years of age) in Finland. Subjects included in the study underwent a clinical interview, electrocardiography and measurement of clinic BP (mean of two clinic measurements) and home BP (mean of 14 duplicate home measurements performed during 1 week). Home BP correlated significantly better than clinic BP with the Sokolow-Lyon voltage (home/clinic systolic: r=0.23/0.22, P=0.60; diastolic: r=0.17/0.12, P=0.009), Cornell voltage (systolic: r=0.30/0.25, P=0.004; diastolic: r=0.21/0.12, P<0.001) and Cornell product (systolic: r=0.30/0.24, P=0.001; diastolic r=0.22/0.14, P<0.001) criteria of ECG-LVH. The correlation between home BP and ECG-LVH increased slightly with the number of home measurements, but even the mean of the initial two home BP measurements correlated equally well (systolic BP), or better (diastolic BP) with ECG-LVH than did clinic BP. In conclusion, home BP measurement allows us to obtain a large number of measurements that have a strong association with ECG-LVH. Our data support the application of home BP measurement in clinical practice.     

高血压病患者动态血压与左心功能相关关系的研究

目的观察收缩压、舒张压分别对左室收缩及舒张功能的不同影响。方法应用诊所血压、２４小时动态血压监测及超声心动图，观察３８例Ⅰ、Ⅱ期高血压病患者血压与左室心肌质量、左室收缩及舒张功能的相关关系。结果２４小时及白天平均收缩压及诊所收缩压均与舒张早期充盈峰值流速（ＥＰＦＶ）呈负相关（Ｐ值均＜００５），２４小时、白天及夜间平均舒张压均与年龄呈负相关（Ｐ值均＜０．０５），与舒张功能各参数之间无相关关系，诊所收缩压与年龄、心房收缩期充盈峰值流速（ＡＰＦＶ）呈正相关（Ｐ＜０．００１及０．０５），夜间平均收缩压及诊所收缩压与左室心肌质量指数呈正相关（Ｐ＜０．０１及０．０５）。而２４小时平均收缩压、白天平均收缩压、２４小时平均舒张压、白天及夜间平均舒张压则均与左室心肌质量指数无明显相关关系。结论２４小时平均收缩压是影响左室舒张功能的重要因素之一，２４小时平均舒张压与左室舒张功能无相关关系。夜间平均收缩压增高是导致左心室肥厚的重要因素之一。随年龄增长，收缩压增高，舒张压下降     

Association of office and ambulatory blood pressure with blood lead in workers before occupational exposure

In view of decreasing lead exposure and guidelines endorsing ambulatory above office blood pressure (BP) measurement, we reassessed association of BP with blood lead (BL) in 236 newly employed men (mean age, 28.6 years) without previous lead exposure not treated for hypertension. Office BP was the mean of five auscultatory readings at one visit. Twenty-four-hour BP was recorded at 15- and 30-minute intervals during wakefulness and sleep. BL was determined by inductively coupled plasma mass spectrometry. Systolic/diastolic office BP averaged 120.0/80.7 mm Hg, and the 24-hour, awake, and asleep BP 125.5/73.6, 129.3/77.9, and 117.6/65.0 mm Hg, respectively. The geometric mean of blood lead was 4.5 μg/dL (interquartile range, 2.60–9.15 μg/dL). In multivariable-adjusted analyses, effect sizes associated with BL doubling were 0.79/0.87 mm Hg (P = .11/.043) for office BP and 0.29/?0.25, 0.60/?0.10, and ?0.40/?0.43 mm Hg for 24-hour, awake, and asleep BP (P ≥ .33). Neither office nor 24-hour ambulatory hypertension was related to BL (P ≥ .14). A clinically relevant white coat effect (WCE; office minus awake BP, ≥20/≥10 mm Hg) was attributable to exceeding the systolic or diastolic threshold in 1 and 45 workers, respectively. With BL doubling, the systolic/diastolic WCE increased by 0.20/0.97 mm Hg (P = .57/.046). Accounting for the presence of a diastolic WCE, reduced the association size of office diastolic BP with BL to 0.39 mm Hg (95% confidence interval, ?0.20 to 1.33; P = .15). In conclusion, a cross-sectional analysis of newly hired workers before lead exposure identified the WCE as confounder of the association between office BP and BL and did not reveal any association between ambulatory BP and BL.     

Different classifications of nocturnal blood pressure dipping affect the prevalence of dippers and nondippers and the relation with target-organ damage

OBJECTIVE: We assessed how different definitions of the awake and asleep periods and use of various blood pressure (BP) indices affect the extent of the nocturnal BP dip, the prevalence of dippers and nondippers, their respective reproducibilities and the relation of nondipping with target-organ damage. METHODS: We performed 24-h ambulatory BP monitoring twice and determined the left ventricular mass index and urinary albumin excretion as indices of target-organ damage in 150 hypertensive patients (off-medication). Awake and asleep periods were assessed using fixed and diary time methods, covering all readings available (wide) or excluding morning and evening transition hours (narrow). Nondipping (BP dip < 10%) was established for systolic BP and diastolic BP, their combinations (and/or), and mean arterial pressure. RESULTS: The different awake-asleep definitions caused significant variation in both the extent of the BP dip and the number of dippers and nondippers in comparison with the wide diary definition (i.e. use of actual awake and sleep periods). The prevalences of dippers and nondippers also varied significantly with the BP index. Reproducibility analyses of the BP dip and the dipping status yielded repeatability coefficients (expressed as percentages of nearly maximal variation) between 42.39 and 48.71%, and kappa values between 0.323 and 0.459, respectively. Some classifications, but not all, discriminated significantly between consistent dippers and nondippers in terms of left ventricular mass index or urinary albumin excretion. CONCLUSIONS: Use of different definitions of awake-asleep and BP indices affects significantly the classification of nocturnal BP dipping and its relation with hypertensive target-organ damage.     

Early morning home blood pressure control among treated patients with controlled office blood pressure

Elevated morning blood pressure (BP) has a significantly increased risk of cardiovascular events, so morning BP is of substantial clinical importance for the management of hypertension. This study aimed to evaluate early morning BP control and its determines among treated patients with controlled office BP. From May to October 2018, 600 treated patients with office BP < 140/90 mm Hg were recruited from hypertension clinics. Morning BP was measured at home for 7 days. Morning home systolic blood pressure (SBP) increased by an average of 11.5 mm Hg and that morning home diastolic blood pressure (DBP) increased by an average of 5.6 mm Hg compared with office BP. Morning home SBP, DBP, and their moving average were more likely to be lower among patients with a office SBP < 120 mm Hg than among patients with a office SBP ranging from 120 to 129 mm Hg and from 130 to 139 mm Hg (P < .001). A total of 45% of patients had early morning BP < 135/85 mm Hg. The following factors were significantly correlated with morning BP control: male sex, age of <65 years, absence of habitual snoring, no drinking, adequate physical activity, no habit of high salt intake, office BP < 120/80 mm Hg, and combination of a calcium channel blocker (CCB) and angiotensin receptor blocker or angiotensin‐converting enzyme inhibitor (ARB/ACEI). Less than half of patients with controlled office BP had controlled morning BP and that positive changes may be related to an office BP < 120/80 mm Hg, combination of a CCB and ACEI/ARB and a series of lifestyle adjustments.